Friday, 30 May 2014

Attachment Parenting vs the NHS – what’s the problem?

I am a mum of two whose ethos, I would say, is pretty sympathetic
to "attachment parenting". In my view, we are basically mammals, and
natural birth, breastfeeding, co-sleeping and baby-wearing are all
normal and natural things for mothers and babies. Here’s the thing, I am
also a qualified paediatric nurse. And NHS professionals often seem to
have a problem with attachment parenting.

Many parents, including myself, have encountered a range of
health professionals including doctors, nurses, midwives, health
visitors and dieticians who are less than supportive of this approach.
They may even be downright negative or antagonistic about your
childrearing decisions, as though they are somehow new-fangled and
dangerous! Why is this? Why are child-rearing practices common in most
of the world, and common in the UK until recently, viewed with such
suspicion? Well, I guess I can look back to my own nurse training and
experience on the wards to help me answer this.

Fundamentally, parents assume a high level of training and
knowledge about birth, child development and child nutrition from our
NHS practitioners, and actually, this is not necessarily the case. Each role is highly specialised. While the NHS is keen to promote breastfeeding, as
a paediatric nurse, I received no training on how to support a
breastfeeding mum. I’m sure the role of breastfeeding in terms of
nutrition and immunity was at some point mentioned on my course but we
were not trained in helping a baby latch on or how to help a mum to
maintain her milk supply if the baby can’t feed. I think we were
supposed to just pick it up. You could argue that this is an essential
skill for staff working on wards with newborns. I am prepared to bet
that doctors do not get this training. It is the role of midwives, health
visitors and lactation consultants, and, as we know, they are in short supply, lacking the time to
give the help and support they may well want to give. This is, of
course, the irony in televised debates about breastfeeding – the medical
expert they whip out is never a lactation consultant or a midwife, it
is a male doctor who has probably had next to nothing in terms of
lactation training or experience!

Conflicts are also cultural – while parenting may feel like it
should be about instinct, warmth and closeness, the NHS runs according
to a scientific work culture. In health, we work on
numbers, percentages, weights, millilitres, on hourly routines and
schedules. Evidence-based practice for successful outcomes. With unwell children or babies failing to thrive, we have to
keep strict records of input and output and weights. Writing “had a 5
minute breastfeed” is very unsatisfying. We want to write, “took 100ml”. It doesn’t matter whether it is formula or expressed breast
milk but part of doing our job is making sure the baby is getting
the target fluid intake for adequate hydration, nutrition and growth. In this
situation, it is unsurprising that mothers of babies in Special Care
Baby Units feel pressured to accept bottle-feeding; staff are convinced
it is the only way to know whether the child is feeding properly. We know about the manifold benefits of breast-feeding. For sick babies, we think
about milk in tummies, ticks on charts, and for good reason.

Also, us medical people are deeply paranoid. We have seen very
sick babies, traumatic births and deaths, tragic accidents. We want to
minimise risk as much as we can. I know two female doctors who opted for
elective C-sections because they had become too scared of natural
delivery – they had developed a skewed vision of birth during their
training and practice and perceived a major operation within the
familiar medical environment a safer, more predictable prospect.
Similarly, no one is more fearful of home birth than a doctor or nurse
working in A&E or the Neonatal Unit because they only see the cases
where things don’t work out as planned. After a placement in NICU, I
myself chose to have both my children in birth centres in hospitals,
medical help at hand. Once you are in that mind-set it is very hard to
overcome it. Any risk must be avoided – relating to birth, sleeping
arrangements, or even baby-wearing – after all, what happens if you
fall over?? Have you thought about the head injury your baby could
sustain??

Then there’s the liability question. In an increasingly litigious culture, health professionals are under pressure. Co-sleeping has been a
hugely controversial issue in this country, particularly in relation to
sudden infant death. Health visitors and midwives must advise that
the baby sleeps in a cot near the parents’ bed but when a parent
expresses an intention to co-sleep, the practitioner should give advice
about how to do so safely – avoiding alcohol and drugs,
preventing suffocation under bedding etc. NHS professionals are always
at risk of being struck off or sued if they give incorrect advice or
care and it is small wonder that health visitors may err on the side
of caution and advise against co-sleeping to protect themselves from any
perceived risk. After all, their career is at stake.

I guess the thing is, people working in health are working to
government protocols, NICE guidance, trust policies. In a way, it
doesn’t matter what our personal view or experience is, we
are representatives of a service. I personally have toyed with training
as a health visitor – helping parents and young children find their
feet, family friendly hours, what’s not to like? But then, it would
involve a lot of hypocrisy on my part. I don’t think I could tell a mum
not to co-sleep. I slept with my parents when I was little, both my
babies have slept in our bed. I don’t think I could advise parents to
try controlled crying, a recommended option according to the Solihull Approach leaflet given to me by my health visitor. It might work for some people, but I cannot leave
a baby to cry.

That’s actually a good thing about my paediatric experience. We
never let babies cry if we could possibly avoid it. Right now, across
the country, nurses, health care assistants and students are rocking babies
at nursing stations or singing them to sleep in equipment cupboards or
treatment rooms so their mums can get a bit of shut-eye. I have even seen the Paediatric Nurse Practitioner, in charge of the whole hospital on a night shift, stopping to shush and swaddle.

Nowadays too, the NHS is focused on family-centered care. We recognise the importance of
attachment and try to keep families together as much as possible. After
all, all a child really wants and needs is the person they love the
most, be it mummy, daddy or granny. So for child inpatients, rather than
sending parents home like they did in the 50s, we find a way so that
they can stay 24 hours, either in a put up bed next to their child or in
local accommodation Kangaroo care is also now widely encouraged in
Neonatal Units across the country and is a brilliant way for Dads to bond with new infants too. For all the negative publicity about NHS
staff these days, in paediatrics at least, I only ever saw people who
genuinely cared and usually went above and beyond to help families
experiencing tough circumstances.

So while we may end up frustrated and irritated by our
encounters, I guess it’s helpful to recognise why health professionals
act the way they do and also accept their good intentions. If you find a
good one, be it a GP, midwife, health visitor or nurse, hang on to them.
Someone who reassures you, empowers you when you feel vulnerable and
helps you trust your instincts is a good person to have around. After
all, these people give you advice but you are in charge. Because no one
knows your child like you do.

7 comments:

Interesting article. After having a traumatic birth mostly due to the attitudes and actions of medical staff i find it very difficult to trust medical staff. That being said, if you did want to become a HV you wouldnt have to recomend CIO. My HV is lovely and was suportive of breastfeeding, cosleeping and told me to never leave him to cry.

Thanks for your comment. I've written a bit more about birth here if you're interested http://www.feministmum.co.uk/2014/02/if-giving-birth-is-safer-than-at-any.html. It's great that you have such a supportive health visitor - it is so helpful when you find someone sympathetic to your own instincts. I hope that we will reach a more collaborative approach one day between professionals and parents rather than the top-down leaflet giving that happens a lot.

I'm in the US, but I have to say my experience was the opposite. I took a nursing course while pregnant, where I learned (among other things) that if you're "doing it right, it shouldn't hurt." I had no end of stress, then, when it was incredibly painful. At teach-ins run by LCs I was encouraged to pay tons of money to set up private consult, since obviously I was doing something wrong or perhaps my son was tongue-tied.

Thankfully, in our pediatric practice, one of the pediatricians is an LC and the others are highly knowledgable about nursing. My son's pediatrician told me that I was, in fact, doing it right (my son was gaining like a champ) and that some women simply do have pain. He was right and the LCs were wrong. My OB gave me the best aid ever for my nursing, a topical ointment by prescription, and thanks to my *medical* professionals I had a thereafter lovely experience nursing my son exclusively until he self-weaned at 15 months.

Dear feminist mum, I like yourself am a healthcare professional , a mother, an advocate for attachment parenting and also a feminist. However I feel strongly that your article is unfair to the NHS and fellow healthcare professionals that work with babies and mothers. In some parts even irresponsible, with the fact that you seem to be encouraging mistrust to mothers who are already vulnerable after just having a baby or with having a sick baby.

Having worked in 5 paediatric/neonatal/ maternity hospitals in London. I have never come across a unit that does not actively promote breastfeeding. When breastfeeding is not possible expressed breast milk is always preferable to just formula.

When formula is advocated you need to ask yourself why? it's is normally because for what ever reason breast milk or breastfeeding alone is not an option because mum is not making enough or the baby is too sick to be put to the breast. To imply that the NHS does not advocate breastfeeding is simply not true. We weigh up risk/ benefit for a baby that is failing to thrive or has severe jaundice because mum is not making enough milk. When baby is well enough, we always advocate breastfeeding first then topping up with formula.

My next point of contention is your comment that we as healthcare professionals are more interested in numbers and charts than patients:As a good healthcare professional you need to balance your academic/ scientific, objective observations with tenderness, compassion, patients subjective experience and individual care. As a paediatrician that is how I practice and many of the people I have worked with in the NHS practice. To imply otherwise on wholesale for the NHS is not right or fair and perhaps means you need to re-evaluate your practice or the practice at your hospital.

Finally, why not reduce or eliminate risk, when it comes to caring for the most precious and important thing in your life, your baby, your child. Why do we wear seat belts or ask our children to wear helmets when cycling, why do we put up stair gates. These things encroach on you and your child's freedom and independence but they may save their lives.As a paediatrician I will do anything in my power to avoid seeing that look on a mothers face because I have had to tell her harm has come to her child due to something that could have been avoided. Some things can not be undone once done.

Have you ever thought that the reason infant mortality and morbidity have reduced in this country compared to many other parts of the world or even the UK of the past is because of the advice we now give parents and the interventions we now use.

The advice I give parents is not given to take away the enjoyment of motherhood or to have a negative impact on how she bonds with her baby, and it is most certainly not because I fear for my job. It is because I care and because my training has giving me objective knowledge about how to best prevent harm coming to any child that crosses my path.

The advice we give as healthcare professionals that work with children is information based on more than the experience of one child or one mother, it is objective and reduced from bias. As a mother it is up to you to use that information in a way that you see fit, but please be reassured that the advice we give is in the best interest of your child, perhaps not always in your interests ( where possible we try to do both) but always, always in the interests of your child.

Thank for your comment. I am surprised that you feel so strongly that my article is an attack on the NHS – I have had a positive response from other nurses and parents who feel that open discussion is helpful in understanding more about our experiences of healthcare. I will answer each of your points in turn but I am not entirely sure you read the whole article.

Firstly the breast-feeding/formula question. If you read my post, I state that the NHS actively promotes breastfeeding but there is often not enough support. Are you aware for example how many breastpumps were available on each unit you worked on? In my experience, there might be one per ward if you are lucky, not very helpful if you have several mums wanting it. Hospital and community NHS lactation consultants may work Monday to Friday and have a busy schedule - I wonder how much lactation training you received as a paediatrician working with mums of newborns? When you need breastfeeding help, you need it now.

On the bottle question, I am not suggesting NHS professionals needlessly advocate formula feeding for very sick babies. I state that “It doesn’t matter whether it is formula or expressed breast milk but part of doing our job is making sure the baby is getting the target fluid intake for adequate nutrition and growth”. Bottles and nasogastric tubes allow us to clearly measure fluid intake which is of course vital to prevent dehydration and promote growth in sick infants. Maintaining breastfeeding where possible is important but clearly there are cases where specific formulas are required, Pregestimil for liver babies for example.

Furthermore, I think it is useful for parents to understand how important numbers are in healthcare. Nurses are keeping accurate records of the wellbeing of our patients. Clearly having a clear record of fluid input and output is essential to maintaining hydration, nutrition and growth. I do not see why explaining this is somehow suggesting NHS professionals are uncaring and I rather resent your implication that I need to re-evaluate my own practice. Did you actually read the paragraph where I state that “For all the negative publicity about NHS staff these days, in paediatrics at least, I only ever saw people who genuinely cared and usually went above and beyond to help families experiencing tough circumstances”?

Finally on your point about risk. You are keen to point out that parents need to know the risks. Of course they do. They also need to know the likelihood of that risk. Home birth is an interesting case in point because many health professionals feel very anxious about the risks of home birth. However, NICE has recently advised that women expecting their second child should be encouraged to consider homebirth. I am not a home birth advocate but I think parents can only make informed decisions if we have an open discussion. Most accidents are avoidable but then, we need to decide as parents which risks are acceptable.

In terms of liability, I have also met health professionals who feel very concerned at the litigious culture that is emerging and feel that they have to over-justify their practice in case of the very small possibility there is a problem down the line. That is a sad situation and not the fault of the professionals or the patients.

I am glad that you care and feel confident in your knowledge to advise parents. It is sad, however, that you feel an open discussion about how the NHS works is an attack on all healthcare professionals. It is a huge institution, we are all likely to have positive and negative experiences as patients, carers and people working within it. Personally I think helping parents understand how the NHS works is a good thing. At the end of the day, whatever advice you give, it is only by collaborating with families that you will get them on-board with the evidence-based care and treatment you prescribe.

Brilliant blog post. I am a paediatric nurse and I've discovered through having my daughter my own strong Attachment Parenting beliefs/practices. My planned home water birth (imagine the shock and concern from my hospital colleagues that this was my birth plan!) was unfortunately derailed by pre eclampsia, I'm breastfeeding my daughter at 9 months with no plans to stop (mind you, she doesn't have teeth yet!), I babywear and adore it, and we part-time co-sleep with her in our room after co-sleeping full time for the first 7 weeks.

Being a mum has challenged so many of my ideas about parenting and my beliefs and practices are often incongruous with my training and the NHS model. But I also struggle with the negativity and mistrust of healthcare staff and medicine in some of the Attachment Parenting/Natural Parenting circles I'm in. I've been thinking about starting my own blog as I have so much to say! I'll be following your blog with interest from now on.

Hey,My mother's feminist principles colored each aspect of my life. As a young lady, I wasn't even permitted to play with dolls or stuffed toys in case they brought out a maternal instinct. It was drummed into me that being a mother, raising youngsters and running a house were a type of slavery. Having a profession, venturing to the far corners of the planet and being free were what truly mattered as per her.Thank you so much!!!~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~>>Medical device consultancy